The cultural language of pain: a South African study

Abstract

Background: Culture is the framework that directs human behaviour in a given situation. Accordingly, culture also influences the meaning and expression of pain. However, the influence of culture on the communication of pain is not always understood and considered by healthcare practitioners. It is often erroneously anticipated that all children (irrespective of cultural origin) will express pain either through quiet endurance or loud verbal complaints. This view could contribute to the inadequate management of pain that is so often described in pain literature. Pain assessment and measurement are integral components of pain management, but are often negatively affected by the healthcare professional’s pre-conceived ideas, as well as by his or her inability to understand the cultural meaning of pain, the non-verbal and verbal language of pain, and the patient’s ability to cope with pain.

Method: The aim of this study was to identify the unique meaning of pain in reference to both general and paediatric pain. In addition, the study aimed at gaining insight into the origin and management of pain. This was achieved by means of qualitative methodology. The study group included people from the South African Nguni and Sotho cultures. A total of 42 participants, who were on average 42 years old, were interviewed.

Results: The study indeed indicated variances between the experience and expression of pain and the generally accepted idea that pain is not culture based.

Conclusion: Health care providers need to be increasingly aware of and sensitive to the cultural expression of pain and how differences in the communication of pain could possibly influence their care plan.

Keywords:

• cultural expression
• Nguni
• pain
• pain assessment
• Sotho
• South Africa

Introduction

Pain is a major symptom of disease and injury and one of the main reasons why people seek health care assistance. Yet estimates from the World Health Organization indicate that 7.5 billion people globally do not have access to adequate pain control, while inadequate pain support has been documented in more than 150 (mostly developing world) countries.^1,2 The ability to manage pain pharmacologically is a major factor that separates developing countries from developed countries. Sub-Saharan Africa carries more than 24% of the global burden of disease and, according to Kumar, children living in Africa are more likely to face illness and death before the age of five than in any other region in the world.³ These facts highlight the potential for pain and suffering for children living in sub-Saharan Africa.

The meaning and expression of pain are influenced by culture, yet few have studied the influence of culture on pain.⁴ Culture has been identified as a major barrier to pain relief in Africa and failing to recognise cultural influences in pain management can contribute to cultural conflict, miscommunication, misdiagnosis, inappropriate care and ineffective patient care. Cultural factors related to pain include: pain expression, pain language, the cultural meaning of suffering, traditional healers and remedies and social roles, perception and expectation.^5,6

Understanding the significance of traditional medicine and how it relates to pain is crucial to unravelling the complex African view of illness where disease, injuries and misfortune can be attributed to a combination of natural causes, witchcraft and unappeased ancestral spirits. In the Nguni culture, for example, beliefs surrounding pain are intricately linked to communication with ancestors who are seen as spirits who are actively involved in the world of the living. Similarly, Sotho culture holds the belief that when an ancestral spirit (Balimo) is angered it can cause sickness and misfortune, which result in pain (as a form of punishment).⁷ The traditional view that pain can be controlled only if the ancestors are appeased impacts on the treatment of pain. In both cultures children are taught to endure pain with stoicism and resilience.^8,9

The ratio of traditional healers in sub-Saharan Africa is set at 1:500 people in comparison with 1 medical doctor per 40 000 people. It is therefore clear that traditional medicinal remedies are more accessible and play a major role in sub-Saharan Africa where 80% of the more than 1 billion people in 54 African countries still make use of traditional medicine.¹⁰

In order to provide for the pain requirements of culturally diverse patients, health care professionals need to develop an increased awareness and understanding of the influence of culture, and the expression thereof in different languages, on their patients’ pain perceptions and behaviour. Levin, in a survey on barriers in health care delivery at the Red Cross War Memorial Hospital in Cape Town, South Africa, found that 64% of the sample population had indicated difficulties in either understanding or communicating with their doctors.¹¹ Schlemmer and Marsh also reviewed the effects of language barriers in South African hospitals and findings from their study revealed that language barriers placed severe limitations on the patient’s ability to communicate pain and anxiety to those responsible for his/her care.^12,13

Sample and methodology

The goal of this paper is to describe and interpret South African Nguni and Sotho perceptions of physical pain and to provide new insights in this regard. A qualitative study was conducted to determine said perceptions.

Since this research study is exploratory in nature, and aims to gain knowledge regarding traditional African perceptions and treatment of pain, the nonprobability method of purposive sampling was employed, and thus specific individuals from specific cultural groups were identified. The only exclusion criterion was culture as defined by the Constitution of the Republic of South Africa. However, to streamline the data analysis and result presentation the cultural groups were clustered into two bigger groups, namely the Nguni group (isiNdebele, isiXhosa, isiZulu and siSwati) and the Sotho group (Sesotho, Sepedi, Setswana).¹⁴

There was no control group included in the study as the aim of this qualitative study was not to address any threats to the validity of the data, but rather to elaborate on the richness of the group studied and to identify their commonalities and differences within the group. Therefore, this research is believed to be a candid portrayal of the experience of members of the Nguni and Sotho cultural groupings who were studied.

The data were collected by using an open-ended questionnaire, which was given to all the participants. No individual was forced to complete the questionnaire. Ethical clearance for this study was granted by the University of the Free State’s Ethics committee (ECUFS179/2012).

The methodology used was to organise the data into categories by coding all the answers using an open-coding technique where general themes were identified and each answer coded accordingly. Once the first round of coding was completed a second round was conducted, namely axial coding. During this phase the researchers organised the themes and coded each theme into subthemes to ascertain whether there were any relationships between any subthemes of the initial open coded themes. Once all subtheme relationships were identified the final round of coding took place whereby selective coding was done and salient themes were identified, together with any subtheme relationship, and these are presented in the results section of this paper.

Results

The aim of this section was to report the salient themes identified after the data were analysed through applying the methodology discussed above.

Table 1 is a summary of the main demographic features of the group.

Table 1: Demographic characteristics of interview participants

Variable	Sotho group	Nguni group
Participants	n = 20	n = 22
Age
Median (range)	41 years (24–64 yrs)	42 years (22–56 yrs)
Gender
Female	11 (55%)	11 (50%)
Male	9 (45%)	11 (50%)
Have children	14 (70%)	17 (77%)

The relevance of the above-mentioned data lies in the almost equal distribution between male and female respondents, nullifying any arguments against gender bias as regards the answers. Furthermore, the average age for both groups places the respondents in the life stage of middle adulthood, as identified by the psychosocial theory of Erik Erikson. The primary developmental task of this period is the nurturing of intimate relationships, managing the household and expanding caring relationships. Since the greater percentage of both groups have children one could infer that most of the respondents would be focused on family and would have a greater awareness of pain as experienced within the family and household context.

Five major themes relevant to cultural pain experiences were identified amongst the two groups in this study and are presented below.

Cultural influence of folklore on the understanding of pain

Pain – both physical and emotional – is described in general terms as: bohloko (Sepedi and Sesotho) and botlhoko (Setswana). Many of the respondents indicated that there was indeed some folklore which spoke about the relevance of pain. One specific (Sesotho) comment alludes to a cultural belief that one should hide emotional pain:

“Folklore about a girl who experienced emotional pain when she could not marry the man she loved. She sat in a hut full of smoke and cried under the pretence that the smoke was to blame for her tears”.

Folklore in the Setswana tradition, Tselane Le Dimo, is relayed to youngsters to illustrate that the desire to hurt other people (based on the legend of the zombie man-eating giant, Dimo, who wanted to eat Tselane, a small girl) will cause pain to be inflicted upon you as a punishment (Dimo was stung to death by a swarm of bees) for doing something bad.

Use of traditional medicine in pain management

With reference to the application of traditional medicine to alleviate pain, a recurrent theme in the more rural areas of South Africa is the use of a traditional healer as the first port of call.

The more urbanised Sotho-group members tend to consult first with a medical doctor; however, should the urban Sotho return home, they would be more willing to use a traditional remedy or izimbiza. Some of the more common remedies include: Kgopane (to treat burns), Tholwana (toothache), Tshikadithate (hip pain), Mokgalo (inflammation of the glands), and Seholobe (cleansing the system).

With regard to the Nguni group the results indicate a lesser importance of traditional medicine. Members in very rural areas would, however, opt for traditional medicine purely because of its greater accessibility and affordability.

Some traditional techniques to get rid of pain include:

“… something called ‘ukugcaba’ (isiZulu) where one needs to cut the painful area with a sharp object, e.g. clean razor, and then apply herbs which are rubbed through the bleeding opening”.

and

“When we were young children in the 1960s my mother and grandmother use to give us children ‘umhlonyane’ (wormwood) for coughs and flu. When we had a cough we would chew this bitter plant, and for flu we would put the plant in our nostrils and we had to inhale. For stomach ache, they would make us drink the bitter juice of ‘ikhala’ (aloe)”.

Gender differences

All three traditions within the Sotho group unanimously agreed that men are not allowed to show their pain (physical or emotional). Expressing pain in any manner is strictly taboo as it is indicative of being weak. A female, on the other hand, should express her level of discomfort in any way possible as it will ensure she receives help.

According to a respondent from the Sesotho tradition:

“‘Monna ke nku ha ile’ literally translates to: a man is a cow, he should not cry. The Sesotho idiom refers to the fact that men are not supposed to cry because it’s a sign of weakness, they are supposed to toughen up and take whatever comes”.

The Sepedi tradition has a similar outlook:

“A man is not expected to cry even if he feels pain, but a woman can cry in case of pain. It is said man is a sheep and a woman is a goat”.

The results for the Nguni group echo that of the Sotho group, namely that men are not allowed to cry – it is almost seen as a taboo within the culture. Young boys are taught that before they can enter manhood (time of circumcision) they should be able to show that they will not cry when they experience pain or hear sad news.

Significance of pain

Many rural people:

“… will think when you have pain there is high possibility that you are being bewitched and would consult a traditional healer as way of finding a solution or some with Christian background will seek a prophet or prayers from the man of God but with the same belief that you are being bewitched”.

In the Sesotho culture:

“There’s this proverb: ‘ngoana mahana a joetsoa o bono aka likhapha’ meaning if you don’t listen to your elders when they tell you not to do something then you will suffer”.

Therefore, when a person is in severe physical pain it is believed that the ancestors are punishing him/her for doing something wrong or not “responding” to a calling.

The salient theme amongst the Nguni group centres on the view that pain is predominately due to physical infection or ailments which are caused by an imbalance in the body. Even though the majority of those interviewed believe that pain can be correlated to physical functioning there were some who believed that it is a way in which their ancestors communicate with them.

Paediatric pain

The majority of the respondents indicated, however, that they would rather take their children to a medical doctor than a herbal doctor. Only when all medical options have been exhausted will they turn to herbal remedies as a last option. At large it would be the task of the mother (or grandmother) to take care of the child and to aid him/her when he/she is in pain.

Discussion and implications for clinical practice

Members of the health care team should be aware of how the personal and cultural beliefs of their patients will influence the way they express pain. Under-treatment or over-treatment might occur if the members of the health care team are not aware of the cultural norms associated with pain and pain expression, since pain is subjective. Culturally sensitive pain assessment should be part of the care plan.¹⁵ Since the pain experience is culturally bound it could be a powerful coping mechanism cognitively in dealing with pain, and as such the meaning of pain should be explored within the clinical setting.¹⁶

Folklore

Stories and folklore are abundant and important in the Nguni group and in them pain is often identified as an outcome of defiant behaviour by the antagonist. Pain – in general – is referred to as ubuhlungu (isiZulu, isiNdebele, isiXhosa) and buhlungu (siSwati). The older members of the families (usually the grandparents) are mostly responsible for telling these stories to children at night to teach them about morals in life. Culture, learned within the family context, can influence young children’s response to pain.¹⁷

The results of the study show the importance of cultural norms (displayed by the folklore) and their impact on the perception of pain. Understanding and sensitivity to these norms could hugely benefit the communication process with individuals in addressing their pain. Without such understanding, the different cultural expression, perception and experience of pain may lead to a disparity within the clinical setting, especially since the manner in which pain is communicated is influenced by cultural and social factors.

Traditional medicine

The plan for pain management should also include sensitivity to a patient’s cultural beliefs as regards traditional medicine. In many cultures it may be more appropriate to use non-pharmacological measures to reduce pain, thereby respecting and acknowledging the cultural relevance of traditional medicine.¹⁸

Gender differences

Cognisance should be taken that gender differences exist and that young and older men are in general not allowed to express their pain verbally. Since women are allowed to express pain verbally it is often erroneously concluded that a female patient is in more/severe pain and a male patient in less pain – this inconsistency could influence the pain treatment plan negatively.

Significance of pain

Pain experience and behaviour are heavily influenced by culture and the socio-cultural (i.e. rural or urban) context of the individuals. Incongruities have been identified between rural and urban members of the two groups studied, where the latter have been more exposed to acculturation and have less family support which influences their perception of pain and the expression thereof by children.

Paediatric pain

According to members of both groups studied children do not necessarily express pain in the same way as adults, as they have not yet been culturally influenced to control their behaviour and emotions.

A salient theme amongst the members of the Sotho group is the view that children experience pain differently from adults since they do not have any preconceived ideas of what is acceptable or not (cultural norms and prescriptions). These indicators are very similar to the indicators displayed by children in general – which means that perhaps, due to their age, culture has yet to influence children’s pain perceptions.

Even though culturally relevant salient themes were identified it is paramount to always acknowledge that individual differences exist within cultural groups; thus, the pain experience should be understood within the context of patients’ beliefs, values, coping strategies and life experiences.¹⁹

Strengths and limitations

The strengths of this study include the actual accounts of experiences of individuals from the identified groups, the depth of the discussions, the scope at which similar themes occurred amongst the participants in this study, and the possibilities the study opens for further research. Limitations of this study include the limited generalisation of the results as well as limited geographical representation of the participants since the research was conducted amongst educated urbanised individuals with limited access to rural areas. A further limitation is the paucity of research on the cultural interpretation and identification of pain in South Africa. The problems associated with untreated childhood pain on the African continent at large and in particular in South Africa necessitates further research on the cultural implications and understanding of pain in children.

Conclusion

Despite numerous publications on African healers and healing traditions, surprisingly little recognition has been given to pain and the management thereof from a traditional African perspective. The significance of pain in the African culture is seen as a natural part of disease or injury and not – as is the case in Western medicine – as a separate entity. Definite gender differences exist amongst members of the groups interviewed and the expression or acknowledgement of pain can almost be described as a cultural taboo associated with weakness and a lack of honour and courage amongst men. Historical folklore, songs and poems describing the stories of fallen heroes and the ancestors are often used to train African children to deal with pain in a stoical and resilient manner. This greatly influences the reaction of members of these cultures towards pain, which explains why health care providers need to show greater sensitivity to the cultural expression of pain.

Additional information

Funding

Funding. The authors received no direct funding for this research.